Society: SSAT

Background and aims: Several small studies reported high risk of progression to high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in Barrett’s esophagus (BE) patients who undergo solid organ transplantation (SOT). However, the major shortcoming of these reports is the lack of a control population. Therefore, we aim to determine the rates of neoplastic progression in SOT patients with BE compared to controls and also the risk factors associated with progression.
Methods: A retrospective case-control study of all patients with a confirmed diagnosis of BE (age ≥18 years) seen between Jan 2000 and Dec 2021 was conducted. Cases were all BE patients who had SOT; controls were all BE patients with no SOT and no immunosuppressant use. Demographics, endoscopic and histological findings, duration of follow-up (in years), history of fundoplication and immunosuppressant use were abstracted. Patients with ≥1 surveillance endoscopies were included to calculate incidence rates of HGD/EAC. Multivariate logistic regression was done to identify the risk factors associated with progression of BE patients to HGD/EAC.
Results: There were 118 cases with SOT (lung =35, liver=35, kidney=35, heart=14, pancreas=2) and 756 controls with no prior history of SOT or immunosuppressant use. Patients with SOT were predominantly younger (p=0.022); male, had lower body mass index (BMI) and active smokers (p<0.001 for all) (table 1). On multivariate analysis, older age, male gender, BE segment length, higher BMI and hiatal hernia were more likely to be associated with progression of BE to HGD/EAC (table 2). BE patients with immunosuppressant medication use were twice more likely to progress to HGD/EAC (p<0.001) (table 2).
Conclusion: Immunosuppressant use increases the risk of neoplastic progression in patients with BE. Therefore, these patients may need more aggressive surveillance. This study has important clinical implications for surveillance in BE patients with SOT.

<b>Table 1</b>: Baseline Characteristics

Table 1: Baseline Characteristics

<b>Table 2: Multivariable Model for Prevalent or Incident HGD/EAC</b>

Table 2: Multivariable Model for Prevalent or Incident HGD/EAC

INTRODUCTION
Screening colonoscopy (SC) is widely accepted and has been shown to decrease the rate of colorectal cancer death. Guidelines and acceptance of screening for Barrett’s esophagus (BE) are less established despite the fact that esophageal adenocarcinoma (EA) remains the fastest increasing cancer in the United States. The aim of this study was to assess the frequency of SC in patients ultimately found to have EA, and to evaluate the presence of symptoms that might have prompted an esophagogastroduodenoscopy (EGD) and potentially earlier diagnosis of the EA.
METHODS
A retrospective chart review was performed to identify all patients who were referred to a single center with esophageal cancer between July 2016 and November 2022. Patients with any histology other than adenocarcinoma were excluded.
RESULTS
There were 221 patients referred with EA. Of these, a SC had been done prior to the diagnosis of EA in 108 patients (49%), 96 men and 12 women. The median age was 66.4 years. A total of 203 SC had been done (range 1-7 per patient). The median interval from SC to the diagnosis of EA was 2.88 years. The highest stage lesion found on SC was colorectal carcinoma in 2 patients and tubulovillous adenoma in 3 patients. There were 36 patients (33.3%) with no findings on SC. At the time of SC, gastroesophageal reflux disease (GERD) symptoms or regular acid suppression medication use was documented in 48.1% of patients (Table). In those with GERD symptoms, the symptoms had been present either life-long or for many years in 69% of patients. Only 19 patients (17.6%) that had a SC had an EGD at any time prior to the diagnosis of EA. In 8 patients, the EGD that found EA was done at the time of SC for anemia, regurgitation symptoms or new-onset dysphagia. A T1 lesion was found in 25% of these patients compared to only 7% of patients that had an EGD separate from the SC (p=0.059). Dysphagia was present at the time of SC in 9 patients, and in 3 patients a SC without an EGD was performed a median of 3 months prior to the EGD that showed EA.
CONCLUSIONS
Nearly one-half of patients ultimately diagnosed with EA had GERD symptoms for many years or were using acid suppression medications regularly at the time of SC, but did not undergo EGD. In 40% of the patients the SC was done within 2 years of the diagnosis of EA. The addition of an EGD at the time of SC in these patients may have allowed early detection of BE or EA.

Background
Transthoracic esophagectomy has historically been characterized as an operation with substantial postoperative morbidity. The application of the robotic surgical platform to enable robotic-assisted minimally invasive esophagectomy (RAMIE) has been prospectively shown to reduce postoperative complications when compared to open resection with thoracotomy. However, RAMIE requires significant institutional investment to fully realize postoperative benefits of minimally invasive resection. We sought to describe improvements in postoperative outcomes over time in our high-volume single-center experience of over 500 RAMIEs.

Methods
Patients undergoing robotic-assisted transthoracic two-field esophagectomy were identified from a prospectively-maintained institutional database (2010-2021). Patients were included if the abdominal portion of the operation was performed open or minimally invasive; all thoracic portions were performed robotically. Primary postoperative outcomes of interest included length of stay (LOS), 30-day pulmonary complication, and 30-day cardiac complication. Cases were separated into cumulative volume quintile (CVQ) by surgical date. Associations between outcomes and CVQ were assessed using regression analysis, as appropriate, with adjustment for clinical factors (age, sex, receipt of neoadjuvant therapy), tumor factors (site, histology, clinical stage), and open vs minimally invasive abdominal portion.

Results
In all, there were 504 RAMIEs identified for study. Median patient age was 66 years (IQR 58-72) and the majority were male (81.9%), were performed for adenocarcinoma (88.1%), and received neoadjuvant therapy (83.9%). Median operative time was 415 minutes, which did not vary by CVQ (p=0.24). Median operative blood loss decreased with increasing CVQ, but not after adjustment for other factors (p=0.79).
The rate of 30-day respiratory complication was lowest (7.0%) in the highest CVQ (cases 404-504), compared to CVQ1 27.7%, CVQ2 16.8%, CVQ3 27.7%, and CVQ4 17.8%, (p=0.001). The association between higher CVQ and reduced rate of respiratory complication remained significant after adjustment for other factors (OR 0.71, p<0.001). Exploratory analysis revealed LOS decreased steadily with cumulative volume (Figure). Median LOS was 10, 10, 9, 9, and 7 days by increasing CVQ (p<0.001) which remained significant in multivariable adjustment (mean -1.2 days per CVQ, p<0.001). No significant association between rate of 30-day cardiac complication and CVQ was observed (CVQ1 28.7%, CVQ2 24.8%, CVQ3 38.6%, CVQ4 27.7, CVQ5 25.0%, p=0.20).

Conclusions
LOS and postoperative respiratory complication decreased significantly over our experience with 500 RAMIEs. The well-established benefits of minimally invasive resection are likely maximized when performed in a high-volume center with experience in optimization of postoperative care.

Introduction
Complex operations have become increasingly centralized at HVCs, which are believed to deliver improved outcomes. While readmission rates have been used administratively to measure surgical performance, surgical volume, as it relates to readmission rates, has not been studied using a population-based database. This study aimed to compare outcomes between HVCs and LVCs in the performance of PEHR.

Methods
The Nationwide Readmissions Database was queried for all patients undergoing PEHR from 2016 to 2018. Patients were excluded if they were <18 years old or had an emergent operation, concurrent bariatric procedure, or a diagnosis of gastrointestinal malignancy. Centers were stratified into percentiles based on elective procedure volume by year. HVCs were defined as in the top 5th percentile (>42 procedures/year), and LVCs were defined as 50th percentile or less (£ 5 procedures/year). Patient characteristics and outcomes were compared with standard statistical methods.

Results
During the 3-year period, 36,484 PEHR patients were identified. Of these, 11,355 (31.1%) underwent PEHR at a HVC and 4,904 (13.4%) at a LVC. Patients were similar in age (65 [55, 72] vs 65 [54, 72] years, p=0.621) and sex (71.8% vs 72.9% female, p=0.145). HVC patients were more concentrated in metropolitan teaching (95.4% vs 48.8%) and large (82.7% vs 33.5%) hospitals (p<0.001). Hospital charges were higher at HVCs ($54,190 [$36,396, $86,599] vs $50,054 [$31,596, $81,821], p<0.001). HVCs performed a higher proportion of laparoscopic (73.3% vs 69.6%, p<0.001), similar proportion of robotic (16.2% vs 15.9%, p=0.661), and lower proportion of open (9.9% vs 13.5%, p<0.001) procedures. HVC patients had less perioperative mortality (0.2% vs 0.5%, p<0.001), major bleeding (0.2% vs 0.4%, p=0.040), pneumonia (0.8% vs 2.3%, p<0.001), respiratory failure (2.2% vs 4.4%, p<0.001), acute renal failure (1.6% vs 2.6%, p<0.001), and sepsis (0.6% vs 1.5%, p<0.001) and shorter length of stay (LOS) (3.0 ± 3.9 vs 3.4 ± 4.6 days, p=0.003). HVCs had lower 30-day (6.6% vs 8.2%, p<0.001), 90-day (9.5% vs 11.1%, p=0.003), and 180-day (11.5% vs 13.0%, p=0.010) readmission rates and readmissions requiring reoperation (0.4% vs 0.9%, p=0.002). In regression analysis, HVCs were protective for 30-day (OR=0.781 [0.642-0.950]) and 90-day readmission (OR=0.837 [0.707-0.990]), mortality (OR=0.247 [0.112-0.544]), and complications (OR=0.764 [0.641-0.910]).

Conclusions
HVCs performed more laparoscopic and fewer open PEHR than LVCs. HVCs had a shorter LOS, lower readmission rates at 30- and 90-days, a reduced rate of readmissions requiring reoperation, fewer complications, and lower mortality rates. Procedure volume was independently predictive of improved outcomes in PEHR. These results support centralization of PEHR to HVCs.

BACKGROUND: Surgical anti-reflux procedures remain the definitive treatment for chronic, medically refractory gastroesophageal reflux disease (GERD), according to consensus guidelines. Patients with GERD frequently present with extra-esophageal manifestations, such as laryngopharyngeal reflux. It may be difficult to discern GERD as the cause of the patient’s condition, and multiple specialist consultations may occur to rule out other etiologies. The choice of initial referral, the timing of referral from diagnosis, and the patient’s comorbidity burden may impact timing of the definitive management—fundoplication. This study aims to examine referral patterns and co-morbidity status to identify factors that influence duration of time between GERD diagnosis and anti-reflux surgery.

METHODS: A retrospective, 10-year review was performed examining patients ages 18-64 with GERD who underwent Nissen fundoplication between January 1, 2010 and January 1, 2020 at a single tertiary referral center. Patients with peptic stricture, esophageal adenocarcinoma, or Barrett’s esophagus with high grade dysplasia were excluded. Patient demographics and clinical variables were collected. Kaplan Meier estimates and linear regression analyses were performed to analyze the association between initial referral type and time to surgery, number of co-morbidities and time to surgery, PCP type and time to general surgery and/or GI referral, and number of co-morbidities and time to general surgery and/or GI referral.

RESULTS: A total of 426 patients were identified with 37 excluded. Analyses were performed of referrals to otolaryngology (ENT), gastroenterology (GI), or general surgery for ICD codes associated with GERD. Referral to ENT delayed time to surgical treatment by 1.3 years compared to those who were initially referred to GI or general surgery (3.4 vs 2.1 years) (p<0.05). A greater co-morbidity burden strongly delayed anti-reflux surgery from initial GERD diagnosis (p < 0.001). Linear regression analysis found that for each individual co-morbidity, the predicted time from GERD diagnosis to fundoplasty increased by 146 days (Fig. 1 and 2). This relationship was maintained when controlling for the association between number of comorbidities and time to either general surgery or GI referral (p < 0.001). There was no association found between type of PCP (MD, nurse practitioner, or physician assistant) and time to referral (p = 0.72).

CONCLUSION: Our results emphasize the importance of deliberate referral practices for patients with GERD to minimize duration of reflux and mitigate potential complications. A large portion of ENT referrals are made for reflux symptoms, yet our data may indicate a need for a change to local referral patterns, as it suggests that initial referral to gastroenterology and/or general surgery may shorten the time to definitive treatment.

Kaplan Meier estimates showing time in days from GERD diagnosis to fundoplication (x-axis) and probability of having undergone fundoplication (y-axis) and influence of comorbidity burden.

Kaplan Meier estimates showing time in days from GERD diagnosis to fundoplication (x-axis) and probability of having undergone fundoplication (y-axis) and influence of comorbidity burden.

Lowess smoother plot showing a strongly positive correlation between co-morbidity burden (x-axis) and time in days between GERD diagnosis and fundoplication (y-axis).

Lowess smoother plot showing a strongly positive correlation between co-morbidity burden (x-axis) and time in days between GERD diagnosis and fundoplication (y-axis).

Introduction:
Peroral Endoscopic Myotomy (POEM) has revolutionized the treatment of achalasia. A myotomy performed endoscopically can extend more proximally than conventional laparoscopic approaches. As a result, the POEM technique is a useful method to treat spastic esophageal motility disorders. However, the ideal myotomy length is still unknown. The purpose of this study is to describe the clinical outcomes of patients with spastic esophageal motility disorders undergoing a standard (≤10 cm) or long (>10 cm) endoscopic myotomy.

Methods and Procedures:
We performed a single institution retrospective review of a prospective quality database. All patients with type III Achalasia, Distal Esophageal Spasm (DES) and Jackhammer Esophagus (JE) undergoing POEM were included. Manometry confirmed the diagnosis of hypercontractile esophageal dysmotility. Patients underwent either a standard myotomy (≤10 cm) or long myotomy (>10 cm) at the discretion of the operating surgeon. The primary outcome was Eckardt score at follow up, with clinical success defined as Eckardt score less than three. Secondary outcomes included operative time, procedural complications, resolution of symptoms, post-operative pH assessment, reflux severity index (RSI) and GERD health-related quality of life (GERD-HRQL) questionnaire scores. Comparisons were made using chi-square and Wilcoxon rank-sum tests.

Results:
From 2012 to 2022, 53 patients with hypercontractile esophageal motility disorders (n=37 type III achalasia, n=14 DES, n=2 JE) underwent POEM, 15 (28.3%) of which were standard myotomies. The procedure was performed by two foregut surgeons at a single institution. The average length of standard and long myotomies were 8.9 ± 1.9 cm and 19.3 ± 4.7 cm (p<0.001), respectively. There were no differences in operative time (102 ± 58 minutes and 104 ± 44 minutes, p=0.323), intraoperative complication rate (6.7% and 2.6%, p=0.489) or 30-day complication rate (6.7% and 10.5%, p=0.825). Clinical success was comparable between groups at first follow up visit (78.6% and 77.3%, p=0.686) and persisted for both groups up to the fourth follow-up at a median of 17 months post-op (Table 1). At one year, differences in RSI (11.5 ± 12.3 and 14.1 ± 13.9, p=0.872), GERD-HRQL (5.6 ± 5.3 and 9.5 ± 10.9, p=0.560) and dysphagia scores (1.0 ± 0.0 and 1.4 ± 0.9, p=0.198) were unremarkable. When comparing myotomy lengths in type III achalasia patients alone, again there was no change.

Conclusion:
In the endoscopic treatment of spastic esopahgeal motility disorders, standard myotomy is non-inferior to long myotomy.

Introduction: Clinical experience has shown that a subset of patients with initial complete resolution of reflux symptoms after magnetic sphincter augmentation (MSA) return with delayed symptom recurrence, concerning for failure of MSA. However, these patients may have no objective evidence of reflux and respond to endoscopic dilation. This group of patients are not well studied. The aim of this study was to characterize patients who present with delayed recurrence of reflux symptoms after MSA and assess the impact of dilation on their outcome.

Methods: This was a retrospective review of 775 patients who underwent MSA between 2013 and 2021 at our institution. Patients with complete resolution of reflux symptoms who had late recurrence of their symptoms were selected. They underwent endoscopy with dilation, pH-monitoring and manometry, at the time of recurrence. Patients were divided into two groups based on whether their delayed recurrent symptoms resolved after dilation. Demographic, clinical and objective testing data were compared between groups, preoperatively, at the time of recurrence and yearly after dilation.

Results: There were 43 (5.5%) patients who were symptom free for at least 18 months after MSA but presented with delayed recurrent reflux symptoms at a mean (SD) of 33.2 (13.0) months. Of these patients, 28 (65.1%) had recurrent symptom resolution after dilation that was durable at a mean (SD) of 17.3 (7.7) months. These patients were younger [52.0 (38-59) vs. 59.8 (53-66), p=0.020], but sex (p=0.185) and BMI (p=0.593) were similar between groups.
Preoperatively, patients who failed to respond to dilation had more frequent severe esophagitis (LA C or D) (26.6% vs. 3.5%, p=0.042), hiatal hernia (93.3% vs. 60.7%, p=0.032) and lower median (IQR) distal contractile integral (DCI) [1155(809-1910) vs. 2236 (1418-3793), p=0.032].
At the time of recurrence, patients who failed to respond to dilation had more recurrent hiatal hernia (33.3% vs. 3.5%, p=0.014), esophagitis (60% vs. 7.1%, p=0.001) and abnormal DeMeester score (>14.7) (66.6% vs. 22.2%, p=0.007). The manometry of those who did respond to dilation showed higher LES resting pressure [35.6(25-42) vs. 22.1(19-28), p=0.037], integrated relaxation pressure (IRP) [14.7(11-24) vs. 11.3(10-13), p=0.048] and DCI [1921(1567-3502) vs. 1083(798-1245), p=0.008].
After dilation, freedom from PPI was significantly higher in the resolution group (82.1% vs. 13.3%, p<0.001). No patients who responded to dilation underwent device removal, compared to 40% of those who failed to respond (p=0.001).

Conclusion: Recurrent reflux symptoms following resolution for minimum of 18 months occur in 5.5% of patients. Those without anatomical failure or objective evidence of reflux can be effectively managed with dilation alone. Patients who fail to respond to dilation have a more severe reflux disease prior to implant.

Background: Despite the availability of prosthetic material to repair recurrent and large complex paraesophageal hernias, recurrences and complications remain unacceptably high. We have recently reported on the use of the patient’s own posterior rectus fascia as a well vascularized onlay graft following as standard cruroplasty. Here we report the early results of a limited series of fifteen patients and offer refinements in the technique using robotic surgery.

Methods: A group of fifteen patients were selected who either presented with large attenuated hiatal hernia defects (n=10) or recurrent hiatal hernias (n=5). Using a robotic technique, the hernia is reduced in the usual fashion. A well vascularized portion of right posterior rectus fascia (approximately 5x7 cm) is then harvested by preserving the vascular pedicle of the round ligament. To alleviate any tension, the flap is passed under the left lobe of the liver, cut to encircle the esophagus, and laid over the cruroplasty. The flap is sutured posteriorly and anteriorly to the diaphragm using interrupted or running sutures (see figure). Postoperative clinical metrics included length of stay, 30-day readmissions, clinical complications, and six month esophagram.

Results: Our series included 12 women and 3 men with mean age of 73 years (62-80), BMI of 27 (22-37) and 9 month follow up. Later in the series, additional time to harvest the flap was approximately 30 minutes. All patients recovered similar to our historical non-flap patients with no alterations in postoperative pain or length of stay. When symptoms regarding any right abdominal pain were specifically solicited, no symptoms were noted. One patient experienced right sided abdominal wall bruising that resolved spontaneously. All patients were satisfied with their repairs at an average follow up of 9 months (0-22 months). To date, no clinical recurrences have been noted based on elicited symptoms, and on available imaging (UGI, CT scan) only one small recurrence (2.7cm) was identified without evidence of clinical symptoms.

Conclusions: The use of posterior rectus fascia for hiatal reconstruction provides many advantages of using durable, autologous, vascularized tissue with a peritoneal lining to buttress the crural repair and is technically feasible with a minimal impact on operative time or post-operative recovery as seen in this 15 patient series. In patents with a difficult to repair hernia, a reinforced repair with the strength of autologous fascia appears to have the appropriate risk-benefit profile over use of mesh. Although in this current series short-term recurrence rates were low, larger sample sizes and long-term outcomes are needed to determine the efficacy of this repair and its selection criteria.

Introduction:
Diaphragmatic reconstruction is a key component of hiatal hernia repair. Results are optimized by minimizing axial tension along the esophagus and radial tension across the diaphragmatic opening. Clinically relevant radial tension is difficult to assess intraoperatively. The shape of the hiatal opening appears to influence tension across the hiatus during closure and could be used intraoperatively to inform operative decision making. We categorized hiatal defects into 4 shapes as a surrogate of radial tension to determine their impact on operative interventions and outcomes.

Methods:
We retrospectively reviewed elective primary hiatal hernias (>3 cm in axial length) repaired at a single center from 2010-2020. Patients with intra-operative unrepaired hiatal photos with at least one year of follow up were included. The hiatal openings were classified into shapes: slit, inverted teardrop, “D”, and oval, with two-person agreement. Shapes were ordered in this manner to represent progression or increasing complexity based on our center’s experience. Recurrence was defined as any anatomical recurrence identified endoscopically or radiographically.

Results:
There were 239 patients studied, of which 111 (46%) recurred. The median follow up was 3.0 years (IQR: 1.8-5.4 years). There were 49 slits, 63 inverted teardrops, 93 “D”s, and 34 ovals. Demographics, comorbidities, and operative characteristics are described in Table 1.

As shape progressed from slit to inverted teardrop to “D” to oval we saw an increase in age (p<0.001), higher percentage of paraesophageal hernias (p<0.001), longer hernia axial length (p<0.001), and increase in hiatal width (p<0.001). Mesh, Collis gastroplasty, and relaxing incisions were more commonly employed in “D” and ovals (p=0.003, p=0.06, p<0.001, respectively).

Radiographic recurrence rates were not statically different amongst the hiatal shapes, but recurrences occurred sooner as shape progressed (p=0.017).

Recurrence free survival analysis with Kaplan Meier curve showed that “D” and oval have a lower recurrence free survival trend compared to slits and inverted teardrops. At 5 years, recurrence free survival trended inversely with increased shape (67% survival, 59%, 51%, and 45%).

Conclusion:
Four different hiatal shapes can be described during hiatal hernia surgery. They provide insight into their chronicity but also a spectrum of complexity with “D” and oval shapes being more complex. While more complex shapes predispose to earlier recurrence; their overall recurrence rates can be equated to less complex shapes with the use of adjunctive measures to reduce hiatal tension. Shape can serve as an intra-operative tool to inform surgeons of the need for adjunctive measures.

Table 1. Patient Characteristics, Hernia Characteristics, Operative Interventions, and Outcomes

Table 1. Patient Characteristics, Hernia Characteristics, Operative Interventions, and Outcomes

Table 2. Recurrence Free Survival by Shape

Table 2. Recurrence Free Survival by Shape

John Campbell

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